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Chapter 23: Problem 115

A client has a head injury due to a motor vehicle accident. What would be the earliest indicator of increased intracranial pressure that the nurse would observe for? A. Seizures B. Ipsilateral pupils C. Headache D. Restlessness

Short Answer

Expert verified
Answer: Headache.

Step by step solution

01

Analyze Option A - Seizures

Seizures could be an indicator of increased intracranial pressure, but they are not necessarily the earliest indicator. Seizures may happen due to other factors such as a pre-existing condition or as a side effect of medication. So, option A might not be the earliest indicator of increased intracranial pressure.
02

Analyze Option B - Ipsilateral pupils

Ipsilateral pupils refer to a condition where the pupils on the same side of the head injury become larger or smaller than normal. This can be an indication of increased intracranial pressure, but it may not be the earliest sign. It is essential to observe other symptoms before concluding increased intracranial pressure.
03

Analyze Option C - Headache

Headache is a common symptom experienced by individuals with head injuries. It is often an early indicator of increased intracranial pressure and can be the first complaint from the client. As the earliest observable sign, headache might indicate the initial increase in intracranial pressure before other symptoms such as seizures or altered pupil size develop.
04

Analyze Option D - Restlessness

Restlessness is a possible sign of discomfort or pain, but it is not specific to increased intracranial pressure. It could be caused by environmental factors, general anxiety, or other medical conditions. Restlessness may eventually present in a patient with increased intracranial pressure, but it is not the earliest indicator.
05

Choose the best answer

Based on the analysis of each option, the earliest indicator of increased intracranial pressure in a client with a head injury from a motor vehicle accident is option C, Headache.

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Most popular questions from this chapter

The nurse is caring for a client in the ER with a spinal cord injury at T4. Assessment reveals a BP of \(76 / 48\), heart rate of 52 , and no reflex activity below the T4 area. The nurse should further assess the client for which of the following complications? A. Neurogenic shock B. Autonomic dysreflexia C. Meningitis D. Increased intracranial pressure

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